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377 Cards in this Set
- Front
- Back
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cardio intro |
wash hands intro, explain, consent, expose (top off) - preserve dignity if lady position: supine at 45o Do you have any chest pain |
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cardio general inspection |
appearance - ill/distressed/in pain environment adjuncts - O2, fluids and medications esp GTN spray |
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Cardio - hands |
temp cap refill <2sec nails tendon xanthomata (hypocholesterolemia) peripheral cyanosis IE stigmata - oslers nodes & JW lesions Tar staining |
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What nail bed deformities do you see in cardio exam |
finger clubbing = IE, cyanotic CHD, atrial myxoma etc koilonychia = Iron deficiency anemia Splinter hemorrhages = IE, trauma eg gardening, joinery Nailfold infarcts = Vasculitis, SLE Nailbed pulsation (qUINCKE'S sign) = AR |
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cardio - wrist |
radial pulse - rate, rhythm, volume & character R-R delay R-F delay ( any shoulder pain) collapsing pulse - grasp forearm and raise |
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what fxs of radial volume and character are you interested in |
bisferiens pulse (mixed aortic disease) slow rising pulse (AS) |
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R-R delay may indicate |
cervical rib, atheroma, embolism, aortic dissection |
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R-F delay may indicate |
coarctation of the aorta, atheroma, embolism, aortic dissection |
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a collapsing pulse suggests |
AR feel for collapsing pulse under your 4 metacarpal heads as you grasp the forearm and raise up |
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Cardio - arm |
BP
If R-R delay then BP in both arms |
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Cardio neck |
JVP
carotids |
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Carotid |
Look Palpate
Patient at 45°, look at left side of neck |
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JVP |
Patient at 45°, look at left side of neck Have you got a sore tummy at all? Demonstrate hepatojugular reflux if not apply pressure at base of neck & rook for external Jugular filling |
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carotid cardiac signs |
very obvious pulsation = Corrigan's sign (AR) carotid is good for assessing pulse character |
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hepatojugular/abdojugular reflex - how does it raise JVP |
increasing venous return from the liver to the heart |
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if you can't see JVP, even after hepato/abdojugular reflex, what else can you do |
apply pressure at the based of the neck & look for external jugular filling this can help convince you that the JVP is below the level of the clavicle and that you are not missing grossly elevated JVP |
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cardiac face |
eyes malar flush mouth |
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in the eyes what are you looking for in the cardiac exam |
corneal arcus = hypercholesterolemia conjunctival pallor = anaemia xanthelasmata = hypercholesterolemia |
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malar flush in the cardiac exam highlights what |
mitral stenosis low CO |
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what do you look for in the mouth in the cardiac exam |
central cyanosis = lung disease, cardiac shunt, abnormal Hb Poor dentition = IE risk factor |
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Inspection of the chest in cardiac exam |
pacemaker/ICD scar (lump) - feel if unsure scars - midline stenotomy - left submammary (left breast if woman) - legs! visible sternal heave |
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midline stenotomy scars may indicate |
CABG valve replacement |
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left submammary scar may indicate |
closed mitral valvotomy pericardial window formation |
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if there is a midline scar, what else would you look for to suggest CABG |
look at legs STRAIGHT AWAY for vein harvesting scar (CABG) if not there, valve replacement more likely |
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palpation in cardiac exam |
apex beat - locate & count rib spaces - define character left parasternal heave thrills |
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where is the apex beat normally palpated |
5th intercostal space, midline clavicular line if cant locate, consider why |
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what are the different ways to characterise apex beat |
tapping = MS heaving = LVH thusting = MR/AR, overload |
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left parasternal heave indicates |
right ventricle hypertrophy |
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thrills indicate |
palpable murmur - grade 4 or above |
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auscultation of the chest in cardiac exam |
apex (bell then diaphragm) axilla (diaphragm) LLSE, pulmonary, aortic (diaphragm) both carotids, holding breath (diaphragm) Apex - patient on LHS with expiration (bell) LLSE - sat forward with expiration (diaphragm) |
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a murmur that radiates to the axilla indicates |
MR |
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both carotids, holding breath suggests |
AS radiation to carotids remember aortic sclerosis doesnt radiate |
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apex - patient on LHS with expiration indicates |
MS |
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LLSE - sitting forward with expiration indicates |
AR |
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back - cardiac exam |
auscultate lung bases - LHF palpate for sacral edema - RHF |
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ankle - cardiac exam |
peripheral edema (RHF, multiple other causes) |
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concluding remarks for cardiac exam |
obs (BP, TEMP, SpO2) abdo exam & peripheral pulses (hepatomegaly & ascites (RHF), splenomegaly (IE), AAA, bruits microscopic hematuria (IE) InV: urinalysis, echo, ECG |
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differentiating between types of cyanosis |
pure peripheral cyanosis = cold blue hands central cyanosis = blue lips and tongue, and when severe can also cause blue hands (usually warm) |
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causes of central cyanosis (blue lips & tongue) |
hypoxic lung disease Right to Left cardiac shunt - cyanotic congenital heart disease - eisenmenger's syndrome methaemoglibinemia (drug/toxin induced) |
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causes of peripheral cyanosis (blue hands) |
peripheral vascular disease raynaud's syndrome heart failure shock central cyanosis when severe |
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irregularly irregular pulse |
AF venricular ectopic beats (VEBs) complete HB + variable ventricular escape |
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to differentiate between AF and VEBs without a 12 lead ECG what can you do |
exercise the patient this will abolish VEBs leaving on AF |
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important causes of AF |
IHD rheumatic heart disease thyrotoxicosis pneumonia/PE/alcohol |
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causes of an absent radial pulse |
congenital (usually bilateral) previous arterial line previous cardiac catheterisaiton atheromatous disease (usually subclavian) arterial embolism (eg AF) surgical ligation |
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JVP abnormalities |
UP & normal waveform: RHF, volume overload, PE. Large a-waves: Pulmonary hypertension, pulmonary stenosis Cannon a-waves: Complete heart block, VEBs Giant v-waves: Tricuspid regurgitation (look for ear-wiggling, pulsatile hepatomegaly) High plateau phase: Constrictive pericarditis Raised and fixed: SVC obstruction |
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Causes of a non-palpable apex beat |
1 Something is between your fingers and the apex - Adipose tissue Obese patient -Air Pneumothorax Emphysernatous bulla (COPD) - Fluid Pleural effusion Haemothorax Pericardial effusion 2. The apex is not in its normal position • Displaced (usually laterally in LHF) • Dextrocardia |
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ddx LVH I Heaving apex |
* Aortic stenosis * Hypertension * HOCM * Coarctation of the aorta |
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Causes of cardiac failure |
1. Pump failure
2. Excessive preload
3. Excessive afterload
4. Isolated RHF
5. High-output cardiac failure (rare)
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1. Pump failure causes |
o Ischaernic heart disease o Cardiomyopathy o Constrictive pericarditis o Arrhythmia (eg. AF, complete HB) o Negative inotropes / chronotropes |
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2. Excessive preload causes |
o Regurgitant valvular disease (MR I AR) o Fluid excess (renal failure, IV fluids) |
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3. Excessive afterload causes |
o AS o Hypertension |
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4. Isolated RHF causes |
o Cor pulmonale (2° chronic lung disease)
o Pulmonary HTN (primary! due to MS) |
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5. High-output cardiac failure (rare) causes |
o Anaemia o Pregnancy o Metabolic (hyperthyroid ism, Paget’s) |
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3rd heart sound (volume overload) causes |
* Normal if < 30 years old * CCF /Ml/ Hypertension/Cardiomyopathy * Aortic/mitral regurgitation * Constrictive pericarditis |
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41h heart sound (pressure overload) causes |
* Always abnormal * CCF / Ml / Hypertension/ Cardiornyopathy * Cannot be diagnosed in the context of AF |
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CHF = |
LHF + RHF (ie biventricular failure) |
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CXR features of LHF (ABCDE) |
* Alveolar oedema * Kerleys lines * Cardiomegaly * Upper lobe venous Diversion * Pleural Effusion |
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Causes of pericarditis |
* Viral (Coxsackie)
* Bacterial / fungal infection
* lmmediately post-MI
* Dressier’s syndrome (2-10 weeks post-MI)
* SLE/ RA /scleroderma
* uremia
* Malignancy |
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MS causes |
rheumatic heart disease 99% |
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MS Presentation |
* SOB & fatigue * Pulmonary oedema / haemoptysis * RHF (late) |
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MS features TIPPQRS |
T = Mid-diastolic I = 1-4 P = Apex P = On LHS & expiration (bell) Q = Rumbling (low-pitched) R = None
S = * Opening snap * Tapping Apex * AF * Loud heart sound * Mitral facies * Signs of RHF |
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MS ECG FEATURES |
AF P mitrale (bifid P waves) |
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MS CXR changes |
enlarged left atrium pulmonary venous congestion |
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DDx for MS |
* Austin-Flint (2° AR) * Carey Coombs (rheumatic fever) * TS (usually rheumatic) |
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Medical Tx for MS |
* AF Rx + anticoagulation * Diuretics |
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MS indications for surgery |
* Valvuloplasty o More than mild disease * Valve replacement! repair o Associated MR o Rigid, calcified valve o Persistent LA thrombus |
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MR causes |
* Rheumatic heart disease * IE * Valve prolapsed * Papillary muscle rupture (eg. Ml) * LV dilatation * Marfan’s * SLE |
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MR presentation |
* SOB & fatigue * CCF (orthopnoea, PND) |
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MR features |
T = Pansystolic I = 1-6 P = Apex P = n/a Q = Blowing S = * Axilla * 3td heart sound * Thrusting, displaced apex * Quiet 1st heart sound * Obliterated 2’ heart sound * AF * Audible ‘click in valve prolapse |
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MR ECG features |
* AF * VEBs |
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MR CXR changes |
Cardiomegaly (late) Cardiac failure [See over] |
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MR DDx |
* VSD (important ddx post-MI) TR (usually functional) - Pulsatile hepatomegaly - Giant v-waves in JVP |
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Medical Tx for MR |
* AF Rx + anticoagulation * Diuretics * ACEi (HTN worsens MR) |
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MR indications for surgery |
More than mild disease Evidence of LV dysfunction Do not delay until irreversible structural damage |
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AS causes |
Rheumatic heart disease Calcified bicuspid valve (age 50-60) Calcified tricuspid valve (age 70+) |
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AS presentation Classic O5CE question |
1. SOB 2. Syncope 3. Angina |
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AS features TIPPQRS |
T = Ejection systolic I = 1-6 P = Aortic P = n/a Q = Crescendo-decrescendo R = Carotids S = * 4th heart sound * HeavIng apex * Slow-rising pulse * Narrow pulse pressure * Quiet 2” heart sound * Ejection click |
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AS ECG FEATURES |
- LVH / LV strain |
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AS CXR changes |
n/a |
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DDx AS |
Aortic Sclerosis [See over] HOCM PS (usually congenital) |
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Medical tx for AS |
n/a |
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AS indications for surgery |
* Symptomatic (prognosis 3 years) * Asymptomatic with gradient> 50 mmHg (controversial) * Valvuloplasty if unfit for surgery |
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AR causes |
* Rheumatic heart disease * IE * Luetic heart disease (syphilis) * Bicuspid valve * Hypertension * Aortic dissection * Marten’s * RA * Ankylosing spondylitis |
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AR presentation |
* SOB & fatigue * Palpitations * (Often asymptomatic) |
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AR features TIPPQRS |
T = Early diastolic I = 1-4 P = LLSE P = Sitting up & expiration (diaphragm) Q Breath-like (high-pitched) R = None S = * 3rd heart sound * Thrusting, displaced apex * Collapsing pulse * Wide pulse pressure * Eponymous signs [See over] * Aortic flow murmur a Austin-Flint murmur (mid-diastolic) |
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AR ECG features |
n/a |
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AR CXR features |
Cardlomegaly Cardiac Failure [See over] |
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AR DDx |
* PR * Graham Steele (PR 2° pulmonary hypertension) |
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AR Medical Tx |
* Diuretics * Vascdilators |
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AR Indications for surgery |
More than mild disease * Do not delay until irreversible structural damage |
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System for Describing Features of a Heart Murmur |
It can be difficult to recall the features bf a murmur. To help do this, use a method such as the TIPPQRS system shown overleaf. Keep reciting T-l-P-P-Q-R-S to yourself until it comes instantly. |
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System for Describing Features of a Heart Murmur |
T Timing I Intensity —thrills are rare so say grade 2 if quiet and grade 3 if loud (don’t say grade I & claim to be an expert!) P = Position of stethoscope on precordium where heard loudest P2 = Position patient in when heard loudest — usually only relevant to diastolic murmurs (AR I MS) Q = Quality R = Radiation S = Systemic features - other heart sounds, characteristics of the apex beat/pulse etc. |
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How to Present Your Findings Go through TIPPQRS |
• On auscultation, the first and second heart sounds are normal (or loud 1quiet / prosthetic / not heard) • There is a T murmur of grade I intensity heard loudest in the P1 area with the patient P2 • The murmur is Q in nature and radiates to the R (or does not radiate) • There is an associated S (3rd/4th heart sounds, apex beat & pulse characteristics etc.) • In summary my findings on examination fit with a diagnosis of - • If native valves: There are no apparent stigmata of IE or signs of heart failure (if you have checked!) • if prosthetic valve: There is no evidence of valvular complication, particularly valve failure or IE |
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Example 1: On auscultation, the 1 and 2 ’heart sounds are normaL There Is an early diastolic murmur of grade 2 intensity heard loudest at the lower left sternal edge with the patient sitting forward and breath hold in expiration. The murmur is high-pitched and breath-like In nature and does not radiate. There is an associated 3 heart sound, a thrusting apex beat and a collapsing pulse. In summary, my findings on examination fit with a diagnosis of aortic regurgitation. There are no apparent stigmata of infective endocarditis or signs of heart failure. |
Example 2: On auscultation, a normal jEI heart sound is audible with a prosthetic 2M heart sound. There is an associated ejection sysiolic murmur of grade 3 intensity heard loudest in the aertic area. The murmur has a crescendo-decrescendo quaiity and radiates to both carotids. This is likely to be a flow murmur across a prosthetic aortic valve. There is no evidence of vaivular complication, particularly valve failure or lE. |
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Heart Murmurs: Notes |
By far the most common murmurs in OSCEs are AS and MR, but AR does pop up pretty frequently in so always palpate the carotid pulse when auscuitating and decide if the murmur occurs with the pulse (ie. systolic) or between pulses (ie. diastolic). Remember left sided murmurs are louder on expiration, right sided murmurs on inspiration. |
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Grading of murmur intensity |
• Grade 1 Very faint, just audible by an expert in optimal conditions • Grade 2 Quiet, just audible by a non-expert in optimal conditions • Grade 3 Moderately loud • Grade 4 Loud with palpable thrill • Grade 5 - Systolic only Very loud with palpable thrill, audible with stethoscope partly off the chest • Grade 6 - Systolic only Very loud with palpable thrill, audible without a stethoscope |
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Stigmata of infective endocarditis |
• Changing heart murmurs • Finger clubbing • Splinter haemorrhages • Mild splenomegaly • Microscopic haematuria • Eponymcius signs (rare!) o Osler’s nodes on finger pulps o .Janeway lesions on palms and soles o Roth spots on the retina |
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Complications of prosthetic valves |
Complications of prosthetic valves • Structural valve failure (ie. regurgitation)• Paravalvular leak* • Thrombosis & obstruction • Infective endocarditis intravascular haemolysis* (Warfarin-related complications) |
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Aortic ‘sclerosis’ fxs nb [*This is more common than structural failure of the valve itself, but will also produce a regurgitant murmur] |
* Asymptcmatic * Does not radiate to carotids * No slow-rising pulse * Normal pulse pressure * 2nd heart sound normal / loud ((a. not quiet) |
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Eponyrnous signs in AR |
* Corrigan’s: Very obvious carotid pulsation * Quinice’s: Nailbed pulsation * Ce Musset’s: Head-nodding * Duroziez’s: Systolic femoral murmur * Traube’s: ‘Pistal shot’ femorals |
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Indications for a bioprosthetic valve (lasts —10 years) |
Indications for a bioprosthetic valve (lasts —10 years) I. Elderly (valve will usually outlast patient) 2. Contraindication to warfarin o Woman of childbearing age o Other contraindications to warfarin need to be weighed carefully against the necessity to repeat surgery |
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resp |
resp |
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resp general inspection |
* Appearance ill I distressed / pain I techypnoeic — * Accessory muscles, pursed lip, wheeze, stridor * Nutritional status I cachexia * Oxygen, fluids and medications * Sputum pot — Look inside it |
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Pursed lip breathing = |
airway obstruction (usually COPD) |
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Nutritional status/cachexia |
COPD, malignancy |
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Oxygen, fluids and medications |
lnhslers & nebulisers especially |
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Sputum pot — Look inside it, describe |
Describe colour, purulence, presence of blood etc. |
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hands |
hands |
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* Nails o Finger clubbing (Inspect carefully) o Koilonychia Peripheral cyanosis Tar staining I coal dust tattoos Warmth Dilated veins 1st web space wasting |
* Ca, ILD, supparative lung disease etc. * Iron dericlency anaemia * PVD, Raynaud’s, CCF or with central cyanosis [See Section II * Smoking / mining (risk of coal-worker’s pneumoconiosis) * Central cyanosis: warm, peripheral: cold [See Section 1] * Hypercapnia * T, lesion (eg. Pancoast tumour) |
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wrists |
wrists |
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* Flapping tremor (asterixis) I Fine physiological tremor I Respiratory rate I Pulse o Tachycardic o Sounding |
* Repiratory I hepatic (renal failure * Salbutamol * Count over 15 seconds whilst pretending to take pulse * Unwell, distressed, saibutamol * Hypercapnia |
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Resp causes of clubbing |
Ca, ILD, supparative lung disease etc |
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Causes of interstitial lung disease |
1. Idiopathic o Cryptogenic fibrosing alvolitis
2. Due to inhaled antigen (Ia. EM) o Bird fancier’s lung o Farmer’s lung
3. Due to inhaled irritant o Asbestosis/silicosis o Coal worker’s pneumocosis
4. Associated with systemic disease o SLE o RA o Sarcoid o Systemic sclerosis
5. Drug-induced o Methotrexate o Amiodarone |
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Resp signs of hyperinflation |
• Reduced cricosternal distance ± tracheal tug
• Increased A-P diameter
• Intercostal indrawing (Hoover’s sign)
• Apex beat not palpable
• Hyper-resonant percussion note |
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Fxs of bronchial breath sounds |
• Loud and blowing • Length of inspiration = expiration • Audible gap between inspiration & expiration • Reproducible by placing your stethoscope over your trachea ancl’flstening |
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causes of bibasal crepitations |
pul edema interstitial lung dis bronchiectasis cystic fibrosis |
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pleural effusion ddx |
transudate: protein <30g/L - CCF - volume overload - hypoalbuminaemia - meig's syndrome exudate: protein >30g/L - infection: pneumonia, TB - infarction: PE - inflammation: RA, SLE - malignancy: bronchogenic, mesothelioma |
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raised hemidiaphragm fxs |
same fxs as having an effusion due to phrenic nerve palsy caused by thoracic surgery/trauma/malignancy |
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lobectomy/pneumonectomy fxs |
check for thoracotomy scar, be careful some examiners may try hide it, so look carefully |
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indications for lobectomy/pneumonectomy |
bronchogenic Ca (25% of NSCLC is resectable) bronchiectasis trauma old tx for TB |
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what sort of exposure do you need for GI exam |
nipples to knees + legs |
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why does wasting in GI exam suggest |
malnutrition and/or synthetic liver failure |
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what causes clubbing in GI exam |
IBD cirrhosis lymphoma coeliac disease |
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what causes leuconychia in GI exam |
hypoalbuminaemia (CLD, other causes) |
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what causes kolionychia in GI exam |
iron deficiency anaemia |
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tendon xanthomata in GI exam suggests |
hyperlipidemia (PBC, cholestasis) |
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what causes dupuytrens contracture in GI exam |
CLD DM heavy labour phenytoin trauma familial |
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do you check for palmar erythema in GI exam |
yes |
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what are the causes of palmar erythema in the GI exam |
CLD
pregnancy
hyperthyroidism
RA Q |
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in the forearm what do you look for in GI exam |
bruising = CLD (due to thrombocytopenia, decreasing clotting factors, falls) IVDU = risk of hepatitis B & C |
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in the face what are you looking for in GI exam |
cushinoid (moon face, plethora, acne, hirsute) = alcoholic pseudocushings (hypercortisolemia 2o stress of repeated alcohol withdrawal) parotid enlargement (sialoadenosis) 2o to alcohol |
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what fxs in the mouth are you looking for in the GI exam |
glossitis = iron/folate/B12 deficiency oral candidiasis = immunodeficiency apthous ulcers = IBD esp Crohns fetor hepaticus = hepatic failure (mercaptan accumulation) angular stomatitis = iron/vitamin B deficiency peutz jeghers spots = peutz jeghers syndrome |
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pursed lips in resp exam indicates |
airway obstruction usually COPD |
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why is it important to look at nutritional status and cachexia for resp exam |
assessing for COPD, malignancy |
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in terms of environmental adjuncts for resp exam what are you looking for |
oxygen equipment, fluids/meds - esp inhalers & nebulisers sputum pot - comment on color, purulence and any blood etc |
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peripheral cyanosis causes in resp exam |
PVD raynauds CHF or with central cyanosis |
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do you assess hand temperature in respiratory exam |
yes, for central cyanosis: warm hands peripheral cyanosis: cold hands |
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dilated veins in respiratory exam indicates |
hypercapnia |
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wasting of the 1st web space in the respiratory exam indicates |
T1 lesion e.g. Pancoast's tumor |
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flapping tremor in respiratory and GI exam indicates |
repiratory/hepatic/renal failure |
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fine physiological tremor in respiratory exam indicates |
salbutamol use |
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what do you assess at the wrist in the respiratory exam |
flapping tremor (asterixis) fine physiological tremor respiratory rate pulse |
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in respiratory exam, what key features of the pulse are worth commenting on |
tachycardic = unwell/distressed/salbutamol bounding pulse = hypercapnia |
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define a bounding pulse |
a strong, forceful heart beat felt in the arteries it doesnt disappear even with moderate pressure over the artery |
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causes of raised JVP in respiratory exam |
RHF including cor pulmonale PE SVC obstruction pulmonary hypertension constrictive pericarditis complete heart block tricuspid regurgitation |
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cushingoid features such as moon face, plethora, acne and hirsuitism are associated with what in respiratory examination |
long term steroid use |
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whats a cause of horners syndrome in respiratory exam |
pancoast tumor |
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causes of central cyanosis in respiratory examination |
lung disease cardiac shunt abnormaly Hb etc |
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candida in the mouth in a respiratory exam can be due to |
steroid inhalers |
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what do you assess in the neck in the respiratory examination |
tracheal position
cricosternal distance tracheal tug on INSPIRATION |
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tracheal deviation |
tension pneu = away from lesion spon pneu = towards lesion effusion = pushes away from lesion |
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cricosternal distance is usually |
2-3 finger breadths |
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cricosternal distance is decreased in |
COPD ie hyperinflation |
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tracheal tug on inspiration indicates |
hyperinflation ie COPD |
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tracheal tug on inspiration features |
the thyroid cartilage which is attached to the trachea moves down on inspiration this is the tracheal tug sign or olivers sign |
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palpable nodes in the respiratory exam indicate |
non tender = ?METS tender = ? infective |
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on examination of the chest whats the importance of AP diameter |
highlights any hyperinflation ie COPD its normally 2:1 ratio 2 across the back and one on the side |
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key features on chest inspection in respiratory examination |
AP diameter scars chest drain sites (old/current) deformity of the chest take a deep breath in - assess symmetry intercostal indrawing (hoover's sign) |
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hoovers sign is what |
intercostal indrawing and indicates hyperinflation ie COPD |
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on palpation of the chest in respiratory exam what are the key areas to focus on |
APEX beat = mediastinal shift (collapse, tension, effusion) RVH (may represent cor pulmonale) chest expansion in 2 places |
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when assessing chest expansion - what is the ONLY feature to comment on? |
SYMMETRY ONLY |
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for percussion and auscultation where should you do it |
back |
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on auscultation of the posterior chest in resp - what key features should you comment on |
vesicular/bronchial breath sounds decreased/absent breath sounds crepitations rhonchi (wheeze) |
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if you hear crepitations on auscultation what should you do |
ask patient to cough and listen again or get them to say 99 each time you touch the chest |
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how do you assess vocal resonance in respiratory examination |
say 99 and listen with steth |
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tactile fermitus features |
get patient to say 99 and put hands on the back
the should increase in consolidation, fluid or mass decreased in conditions the decrease the vibrations: increased fat, air fluid level in chest wall (PLEURAL EFFUSION), emphesema, pneumothorax |
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define tactile fermitus |
its the vibration felt on chest wall due to speech |
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what part of the hand is used to feel for tactile fermitus |
palm |
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why does tactile fermitus increase with consolidation, mass, fluid |
because sound travels easily through fluid than air |
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why in pleural effusion is tactile fermitus decreased |
because the visceral pleural acts as a barrier to some of the vibrations getting through, thus less sound getting through, thus less vibration, thus decreased tactile fermitus |
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sacral edema and peripheral edema in respiratory exam indicates |
RHF which may be associated with cor pulmonale |
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what extra inV should you ask for in the respiratory examination |
sputum pot + analysis obs (BP, temp, SpO2) LFTs, peak flow, CXR, ABG |
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in consolidation what features should you expect |
no mediastinal shift dull percussion bronchial breath sounds increased vocal resonance |
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in collapse what features should you expect |
mediastinal shift towards the collapse dull percussion decreased/absent breath sounds decreased/absentvocal resonance |
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in effusion what features should you expect |
mediastinal shift away if BIG effusion stony dull percussion decreased/absent breath sounds decreased/absent vocal resonance |
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in pneumonectomy what features should you expect |
mediastinal shift towards lesion dull percussion absent breath sounds absent vocal resonance |
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Abdo distension causes |
The 6 Fa: Fat, Fluid, Flatus, Faeces, Fetus, Flipping big masses |
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GI abdomen inspection |
Distension Caput medusae = portal HTN Scars |
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Liver palpation |
Feel for liver edge during inspiration |
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Liver exam - GI |
Take deep breaths in end out for me.
Start in RIF, work towards costal margin
Percuss out upper & lower borders |
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Shifting dullness of GI exam |
Percuss away from mildline to left flank
Leave finger at first point of dullness
Roll patient towards you Percuss again — Still dull? Tympanic? |
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GI auscultation |
Bowel sounds —just below umbilicus
Renal bruits — superior and lateral to umbilicus |
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GI leg exam |
PerpheraI oedema
Erythema nodosum
Pyoderma gangrenosum |
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Ascites causes |
Transudate (Protein < 3OgIL) o CLD (75% of ascites) o CCF o Volume overload o Hypoalbuminaemia (See Appendix o Constrictive pericarditis
Exudate (Protein > 3OgIL) o Infection • TB • Pyogenic infection (Infarction) o Inflammation • Pancreatitis
o Malignancy • Luminal (stomach / colon) • Pancreas • Liver (primary / metastatic) • Ovarian • Lymphoma o Other • Lymphedema • Hypothyroidism |
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Multifactoriat aetiology of ascites in CLD |
1. Portal hypertension
2. Hypoalbuminaemia
3. Salt & water retention (RAAS activation) |
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Gynaecomastia causes |
• Physiological (puberty / elderly)
• Testicular failure o Klinefelter’s syndrome o Viral orchitis / testicular trauma o Haemodialysis
• Increased oestrogen o Chronic liver disease o Thyrotoxicosis o Oestrogen-secreting tumour
• Drug-induced (DISCO MW) o Diqoxin o Isoniazid o Spironalactone o Cimetidine / CCB o Oestrogens o Methyldopa o Tricyclics o Verapamil |
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Hepatomegaly causes INCHIB BIINCH |
• Infection o Hepatitis* o EBV* o Malaria* o Liver abscess • Neoplastic o Primary I metastatic disease • Venous Congestion o RHF o Tricuspid regurgitation o Budd-Chiari syndrome • Heematological o Lymphoma* / Leukaemia* o Myelofibrosis* o Sickle-cell & haemolytic arlaemia* • Infiltrative o Sarcoid* I Amyloid* o Haemochrornatosis o Fatty liver • Biliary o PBC / PSC |
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Typical characteristics of a liver edge |
Smooth: Venous congestion, fatty infiltration Knobbly: Metastases, cysts Pulsatile: TR Tender: Hepatitis, RHF (capsular pain) Bruit: HCC, AV malformation, TIPSS |
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DIFFERENTIAL FOR Splenomegaly |
Massive (MM) - Past Umbilicus o Malaria o MyeloproLiferative (rnyeloflbrosis, CML) Moderate - Up to umbilicus o Lymphoma / Leukaemia o Portal hypertension o Haemolytic anaemia Mild - Hard to GRIP o Glandular fever (ie. EBV) o RA (Feltys syndrome if also down WCC) o infective endocarditis o Pernicious anaemia |
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Extra-intestinal manifestations of IBD |
• Finger clubbing • Mouth ulcers (especially Crohrt’s) • Eyes o Episcleritis o Conjunctivitis • Skin o Erythemanodosum o Pyoderma gangrenosum • Joints o Seronegative spondyloarthropathy • PSC (especially UC) • Amyloidosis (especially Crobn’s) |
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Palsy causes to CN olfactory |
o Trauma o Frontal lobe tumour o Meningitis |
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Causes of any cranial nerve palsy |
Diabetes (due to ‘microangiopathy of the vasa nervorum) Stroke MS Tumour Sarcoid SLE Vasculitis |
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Palsy causes for CN 2 optic nerve |
Monocular blindness • MS • SCA
Bitemporal hemianopia • Pituitary adenoma • Internal carotid artery aneurysm
Homonymous hemianopia • Anything behind chiasm • Stroke / tumour / abscess |
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Oculomotor palsy causes |
o Partial (pupil spared) • Diabetes*
o Complete • PCA aneurysm • Raised intracranial pressure with tentorial herniation |
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CN 4 Trochlear nerve palsy causes |
o Single palsy rare o Usually due to orbit trauma
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Trigeminal nerve palsy CN 5 |
o Idiopathic (trigeminal neuralgia) o Acoustic neuroma o Herpes zoster V |
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CN 6 abducens nerve palsy causes |
o Skull involving petrous temporal o Nasopharyngeal carcinoma o Raised intracranial pressure (false localizing sign) |
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CN 7 VII Facial nerve palsy causes |
o LMN (forehead affected) • Bell’s Palsy • Malignant parotid tumour • Herpes mater (Ramsay-Hunt)
o UMN (forehead spared) • Stroke/tumour |
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CN 8 VIII Vestibulocochlear nerve palsy causes |
o Excessive noise levels o Meniere’s disease o Furosemide o Aminoglycoside antibiotics (geritamicin) |
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CN IX / X / XII CN 9 / 10 / 12 Bulbar PALSY causes |
o LMN (bulbar palsy) • MND • Diptheria • Polio • Guillian-Barre syndrome • Syringobulbia o UMN (pseudobulbar palsy) • MND • Bilateral strokes • MS |
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why is oculomotor palsy in diabetics partial |
ln diabetic oculomotor palsy the pial vessels perfusing parasympathetic fibres are unaffected by the diabetic microangiopathy, hence the pupil is spared (and the palsy ‘partial’) |
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Causes of grouped cranial nerve palsies |
* Cerebeflopontine angle tumour (acoustic neuroma or meningioma) o Corneal reflex lost first = CN 5 o Then VII & VIII o Then rest of CN 5 o Sometimes IX & X * Paget’s disease of bone — impingement of nerves as they pass through bony foramina o affects CN 5, 7 and 8 * Gradenigo’s syndrome (complication of otitis media) o V&VI * Syringobulbia o Bulbar palsy (IX, X & XII) o VIII— vertigo & nystagmus o V facial pain I sensory loss o VII sparing o May also have Horner’s syndrome and features of syringoniyelia |
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UMN cranial nerve signs |
* Facial nerve palsy with forehead sparing (due to ‘bilateral cortical representation of the forehead’) * Brisk jaw jerk * Pseudobulbar palsy |
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SO4 function |
depresses the eye and adducts the eye |
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LR6 |
abducts the eye |
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Extra-ocular muscles |
CN 3 Superior rectus Inferior rectus Medial rectus Inferior oblique CN 4 Superior oblique ‘S04’ CN 6 Lateral rectus — LR6’ |
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differential for ophthlamoplegia |
Myaesthenia gravis Cranial nerve palsy Graves disease Wernicke’s encephalopathy (particularly failure of upqaze) Progressive supranuclear palsy (particularly failure of downgaze) |
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internuclear ophhaImopega features |
Disorder of conjugate lateral gaze caused by lesion in the medial longitudinal fasciculus Causes failure of ADduction of eye on affected side In a left-sided NO - Lateral gaze to left is normal (left eye is being Ac(ucted) - On atempting to look to the right o Right eye ABducts normally o Left eye fails to ADduct and remains looking straight ahead o Right eye consequently displays nystagmus as it attempts to compensate Convergence is preserved (ie. the left eye can ADduct normally as long as the goal is not lateral gaze) |
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differential for Internuclear ophtlmoplegia |
MS (almost always the cause in a young patient) Stroke Lyme disease and TCA overdose are rare causes |
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Interpretation of Rinne’s & Weber’s Tests: |
R: Air> Bone (both ears) W: Central DIAGNOSIS = Normal |
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Interpretation of Rinne’s & Weber’s Tests: CONDUCTIVE HEARING LOSS IN LEFT EAR |
R: Bone >Air (left ear) W: Laterelizes to left ear = Conductive Liearthg loss in Left ear |
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Interpretation of Rinne’s & Weber’s Tests: COMPLETE SNHL IN LEFT EAR |
R: bone > Air (left ear)* W: LateraLizes to right ear = Complete SN deafness in left ear NB In this interesting situation, during Rinnes test sound is conducted via the skull across to the (normal) right ear when bone conduction is tested. Nothing is heard when air conduction is tested. Therefore bone is louder than air. |
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Interpretation of Rinne’s & Weber’s Tests: SNHL IN RIGHT EAR |
R: Air > Bone (both ears) W: Lateralizes to left ear Sensorineural hearing loss in right ear |
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Psdueobulbar palsy features |
UMN causes: - MND - bilateral strokes (e.g. internal capsule) - MS |
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what is used to differentiate between a bulbar palsy and a pseudobulbar palsy |
remember its 9, 10 and 12 THE TONGUE appearance is used to differentiate |
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tongue appearance in bulbar palsy vs pseudobulbar palsy |
BULBAR PALSY - LMN - flaccid tongue - wasted - fasiculating PSEUDOBULBAR PALSY - UMN - spastic tongue - contracted |
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is bulbar pulsy LMN/UMN |
LMN pseudobulbar palsy is UMN |
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other features of bulbar palsy |
drooling dysphonia tremulous lips |
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other features of pseudobulbar palsy |
drooling dysphonia emotional lability |
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regarding UPPER LIMB MOVEMENT - what nerve root and nerve move the upper limb |
Shoulder ABduction C5 Axillary Elbow flexion C5 / C6 Musculocuteneous Elbow extension C7 Radial Wrist extenston C7 Radial Finger extension* C7 Radial Finger flexion C8 Median + Ulnar Thumb ABduction T1 Median Finger ABduction T1 Uinar |
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which nerve root and peripheral nerve does shoulder aBduction |
ROOT = C5 NERVE = AXILLARY |
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which nerve root and peripheral nerve does ELBOW FLEXION |
ROOT = C5/C6 NERVE = MUSCULOCUTANEOUS |
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which nerve root and peripheral nerve does ELBOW EXTENSION, WRIST EXTENSION AND FINGER EXTENSION |
ROOT = C7 NERVE = RADIAL |
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which nerve root and peripheral nerve does FINGER FLEXION |
ROOT = C8 NERVE = MEDIAN + ULNAR |
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which nerve root and peripheral nerve does THUMB ADDUCTION |
ROOT = T1 NERVE = MEDIAN |
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which nerve root and peripheral nerve does FINGER ABDUCTION |
ROOT = T1 NERVE = ULNAR |
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name the reflex and associated nerve root |
Biceps jerk C5 / C6 Triceps jerk C7 Supinator jerk C5 / C6 |
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FLOW FOR UPPER & LOWER NEUROLOGICAL SYSTEM |
TPR - CS (light touch, pain, joint position, vibration) |
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upper limb dermatomes (remember the nerves given are NERVE ROOTS) |
Above shoulder tip C4 Regimental badge area C5 Tip of thumb C6 Tip of middle firiger C7 Tip of pinky C8 Medial mid-forearm T1 |
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clinical features of LMN lesion |
Tone = normal/down Power = reduced ie flaccid Reflexes = reduced Plantars = down Co-ordination = normal Other Features = wasting = fasiculations |
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clinical features of UMN lesions |
Tone = UP i.e. SPASTIC Power = DOWN Reflexes = BRISK I.E. DOWN Plantars = UP i.e. BABINSKI Co-ordination = DOWN Other Features = CLONUS |
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clinical features of EXTRAPYRAMIDAL lesions |
Tone = UP (RIGID) Power = NORMAL Reflexes = NORMAL Plantars = DOWN Co-ordination = DOWN Other Features = resting tremor = bradykinesia = postural instability |
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Cerebellar lesion clinical features |
Tone = down Power = Normal Reflexes = Normal Plantars = DOWN Co-ordination = SIGNIFICANTLY REDUCED Other Features = INTENTION TREMOR = NYSTAGMUS = CEREBELLAR SPEECH (STACATO) |
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Grading of power (0-5) normal resistance with gravity without gravity flicker nothing |
5 Normal 4 Reduced Able to move against resistance 3 Able to move against gravity Unable to move against resistance 2 Unable to move against gravity Able to move if gravity eliminated 1 Flicker of movement only 0 No movement |
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the spinothalamic tracts carries what sensory information/modality |
o Pain o Temperature o Crude touch |
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the dorsal columns carry what sensory information/modality |
o Vibration o Joint position o Fine touch |
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WHAT Pathology of spinal cord sensory tracts affects the spinothalamic tract |
Syringomyelia |
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WHAT Pathology of spinal cord sensory tracts affects the dorsal columns |
o Tabes dorsalis (syphilis) o SCDC |
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Syringomyelia features |
* Expansion of spinal cord central canal due to CSF blockage (commonly CHIARI malformation) * Spinothalamic fibres principally affected * Loss of pain & temperature sensation in ‘cape-lik& distribution over arms, shoulders & upper body * LMN signs in upper limbs, spastic paraparesis of lower limbs * Dorsal column signs develop as canal (syrinx) further expands * Syringobulbia if syrinx extends into brainstem |
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Brachial plexus injuries at birth: |
Erbs Palsy Klumpke’s Palsy |
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Erbs palsy features |
nerve roots affected = C5-7 mechanism of injury: shoulder dystocia during birth clinical features: = Sensory loss down lateral arm = Waiters tip’ position * Shoulder ADducted * Arm internally rotated * Forearm pronated |
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Klumpke's Palsy features |
Lower plexus (C8 — T1) Excessive arm traction during birth Sensory loss in medial forearm & hand Complete claw hand Wasting of small muscles in hand Horner’s syndrome may co-exist |
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LOWER LIMB NEUROLOGICAL SYSTEM name the movement and associated nerve root |
Hip flexion L1 / L2 Hip extension (push heel into bed) L5 / S1 Knee flexion L5 / S1 Knee extension L3 / L4 Ankle dorsiflexion L4 Big toe extension L5 Ankle piantarfiexion S1 |
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what nerve root does the knee jerk reflex |
L3, L4 |
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what nerve root does ankle jerk reflex |
S1 |
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plantar reflex features |
don't worry about nerve ROOT its used to show if there is an UMN lesion or not remember plantar reflex DOWNWARDS = NORMAL UPWARD = BABINSKI reflex = UMN lesion |
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when testing coordination in the UPPER AND LOWER NEUROLOGICAL SYSTEM - what are you actually testing |
CEREBELLAR FUNCTION if poor coordination = cerebellar ataxia |
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what are the dermatomes for the lower legs |
Anteromedial upper thigh L2 Anteromedial thigh above knee L3 Medial mid-leg L4 Middle of dorsum of fool L5 Lateral sole of foot S1 |
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What are the special tests for lower limb neurological exam |
straight leg raise (testing sciatic nerve) femoral stretch test |
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what additional tests would you consider for lower limb neurological exam |
ROMBERGS test and assess gait full neurological exam sensory neuropathy: there (is/ is no) evidence of soft tissue damage spastic paraparesis: examine sensory level on thorax flaccid paraparesis: perform PR & check for saddle anaesthesia InV: nerve conduction studies/CT head/MRI spine |
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what additional tests would you consider for UPPER limb neurological exam |
full neurological exam nerve conduction studies/CT head/MRI spine |
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are there any SPECIAL tests for UPPER limb neurological exam |
NO NO |
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differential for Paraparesis = Bilateral leg weakness |
Acute & progressive — very unlikely in OSCES Spastic paraparesis — Bilateral UMN signs Flaccid paraparesis — Bilateral LMN signs Mixed picture — ie. confusing! |
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differential for Paraparesis = Bilateral leg weakness Acute & progressive — very unlikely in OSCES |
o Acute spinal cord compression (UMN) o Cauda equine syndrome (LMN) o Guillain Barre syndrome (LMN) |
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differential for Paraparesis = Bilateral leg weakness Spastic paraparesis — Bilateral UMN signs |
o Sagittal sinus lesion (ONLY MOTOR SIGNS) * Parasagittal meningioma o Bilateral strokes o Syringomyelia (with upper limb signs) o Cord trauma (eg. RTA) o Cord compression * Extradural tumour * Disc prolapse * Spondylosis / osteophytes o Intrinsic cord disease * Tumour (eg. glioma) * Vascular rnyelopathy * MS |
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differential for Paraparesis = Bilateral leg weakness Flaccid paraparesis — Bilateral LMN signs |
o Polio o Mostly motor peripheral neuropathy * Guillain Barre * Lead poisoning * Charcot Marie Tooth o Mixed peripheral neuropathy (ALWAYS HAS MARKED SENSORY LOSS) * Diabetic * Uraemic * Vitamin deficient (B12, folate, thiamine) * Paraneoplastic * Alcoholic |
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differential for Paraparesis = Bilateral leg weakness Mixed picture — ie. confusing! |
MND2 (causes almost any motor picture) SCDC |
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differential for unilateral leg weakness |
* UMN o Stroke o Tumour o MS * LMN o Root lesion o Nerve lesion |
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SCDC (B12 / folate deficiency) features |
* Spastic paraparesis * Upgoing planters * Reduced knee jerks * Loss of ankle jerks * Dorsal column loss o Loss of vibration sense o Loss of joint position sense o Sensory ataxia (+ve Romberg’s) |
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Amyotrophic Lateral sclerosis (Type of MND) features MOST COMMON INHERITED MND |
LMN SIGNS * Weakness * Wasting * Fasciculation UMN SIGNS * Spasticity * Brisk reflexes |
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differential for foot drop |
* Common peroneal nerve palsy * Stroke * L4 / L5 root lesion * MND * Charcot-Marie-Tooth syndrome |
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1 In any case of spastic paraparesis look for ‘sensory level’ on thorax (cord trauma / compression / disease)
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3 In cases of cord compression look for LMN signs at the level of compression |
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MEDIAN nerve root |
C5, C6, C8, T1 |
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ULNAR NERVE ROOT |
C8, T1 |
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RADIAL NERVE ROOT |
C7 nb axillary also C7 |
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structure for hand nerves EXAM LIPSS |
LOOK/INSPECT POWER SENSATION SPECIAL TESTS |
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median nerve exam |
LOOK/INSPECT - thenar wasting (begging position) - carpal tunnel decompression scar (palm/wrist) POWER - thumb ABduction SENSATION - lateral side of INDEX finger SPECIAL TESTS - Tinel's test (tap) - Phalen's test (reverse prayer) |
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ulnar nerve exam |
LOOK/INSPECT - hypothenar wasting - back of hands for interossei wasting - partial claw hand (ring and pinky; weak medial lumbricals) - check elbows - scars, trauma/deformity POWER - finger Abduction SENSATION - medial side of pinky SPECIAL TESTS - Froment's test = +ve if thumb bends = aDDuctor policis WEAKNESS |
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Radial nerve exam |
LOOK/INSPECT: - wrist drop POWER - wrist and finger extension SENSATION - first dorsal interosseous/web space SPECIAL TESTS - NON |
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What extra tests would you do for hand nerve exam |
full neurological exam +- nerve conduction studies |
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Sensory innervation of the median nerve |
Lateral palm Thumb & lateral 2½ fingers |
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motor innervation of the median nerve |
LOAF L = Lateral 2 lumbricals O = Opponens policis A = Adductor policis brevis F = Flexor policis brevis |
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median nerve mechanism of injury |
carpal tunnel syndrome |
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features of median nerve palsy |
Thenar eminence wasting Normal posture Pain / sensory loss as above Weak thumb ABduction Tinels / Phalen’s +ve |
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sensory innervation of the ulnar nerve |
Medial hand (palm & dorsum) Medial 1½ fingers |
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motor innervation of the ulnar nerve |
dorsal interossei medial lumbricals |
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ulnar nerve mechanism of injury |
elbow (funny bone) trauma hand trauma (RARE) |
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features of ulnar nerve palsy |
Hypothenar eminence wasting lnterossei (1st most obvious) wasting Partial claw hand Pain / sensory loss as above Weak finger ABduction Froment’s sign |
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features of radial nerve palsy |
sensory innervation: Lateral dorsum of hand (No fingers) motor innervation: Extensors - fingers - wrist - elbow mechanism of injury: - humeral shaft # features: - Wrist drop - Pain / sensory loss as above - Weak finger / wrist extension |
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C7 radiculopathy |
Note that a C7 radiculopathy causes a similar motor deficit to radial nerve palsy, but with sensory loss in the index and middle fingers rather than on the dorsal interosseous space |
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T1 lesion causes |
o Cervical spondylosis o Pancoast tumour o Plexus trauma / birth injury (Klumpke’s palsy) |
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T1 lesion clinical features |
o Total claw hand (all lumbricals lost) o Wasting of small muscles in hand o Pain I sensory loss in medial forearm o Horner’s syndrome may co-exist |
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differential diagnosis (?causes) for carpal tunnel |
idiopathic pregnancy RA hypothyroid diabetes acromegaly |
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saturday night palsy definition |
compression of the radial nerve against the humerus by falling asleep with your arm over the back of the chair |
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EXTRAPYRAMIDAL SYSTEM / TREMOR / PARKINSONS EXAM structure |
intro inspection - facial expression - mask like - flexed extrapyramidal posture (ie head flexed off pillow, simian posture on standing i.e. stooped posture, hands flexed) TRAP (P = postural instability) - T = tremor (look; head titubation; spread fingers with hands out; flapping) - R = check tone - A = opposition and play piano - P = other tests - glabellar tap - speech - writing function - tap turn - button - coins |
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when assessing postural instability in extrapyramidal/tremor/parkinsons exam what features are you looking for |
o Hesitancy o Shuffling gait o Loss of arm swing o Hurried steps o Festination o Retroopulsion |
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glabellar tap test features |
o Ask patient to fix eyes on a point on the wall I am going to tap on your forehead” o Tap repeatedly between their eyes with your index finger o Look for failure of attenuation of the blink response IN NORMAL INDIVIDUAL BLINKING WILL STOP AFTER 2-3 TAPS |
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speech test in parkinsons exam |
state name and DOB listen for slow, monotonous speech |
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writing test in parkinsons exam - what are you looking for |
micrographia = small handwriting |
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what additional tests should you do for extrapyramidal system exam |
Assess for evidence of a Parkinson’s Plus syndrome o Full neurological examination (looking for multisystem atrophy) o Erect & supine BP (looking for shy drager syndrome) o Eye movements (looking for progressive supranuclear palsy) |
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Causes of Parkinsonism |
* Idiopathic Parkinson’s disease * Drug-induced Parkinsonism o Lithium o Penothiazine antipsychotics o Atypical antipsychotics (less so) o Metoclopramide * Parkinson’s plus syndrome o Shy-Drager syndrome (autonomic failure) o Multi-system atrophy (cerebellar and pyramidal features) = degenerative disorder o Progressive supranuclear palsy (ophthalmoplegia, especially downgaze) * Atherosclerotic pseudoparkinsonism (legs only, less tremor) * Dementia pugilistica o Parkinsonism secondary to repeated head trauma associated with boxing (eg. Mohammed All) |
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Conditions with similar presentations to Parkinsonism |
o Benign essential tremor o Wilson’s disease - Tremor - Dyskinesias - Psychiatric illness - Hepatotoxicity - Kaiser-Fleisoher rings in eyes |
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Long-term complications of L-Dopa therapy |
o Increasingly severe Parkinsonism o Autonomic neuropathy o Dysphagia o Dementia o Dyskinesias o Motor fluctuations (on-off / end of dose) |
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differential diagnosis for tremors |
* Resting: Parkinsonism * Flapping: Hepatic failure (encephalopathy), respiratory failure, renal failure * Intention: Cerebellar lesion * Postural: Benign essential tremor, physiological tremor |
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Benign Essential Tremor aka |
essential tremor |
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benign essential tremor features |
cause unknown likely genetic component since FHX in 50% improves with ETOH progressive exam: - mild asymmetry common - slower approx 7Hz - titubation in 50% - postural & action management: - BB - gabapentin if CI |
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Exaggerated Physiological Tremor features |
cause - fever - hyperthyroidism - anxiety states - medication induced e.g. salbutamol - non progressive exam - usually symmetrical - faster approx 5Hz - no titubation - usually purely postural (abolished by action) mgmt: - treat/remove cause - BB (or gabapentin) sometimes needed |
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Cerebellar function (i.e. coordination) exam structure |
inspection - bruising/scars = recurrent falls - symetry, muscle wasting, fasciculation = LMN lesion head - nystagmus - speech (looking for slurred speech): say baby hippopotamus upper limbs - tone (normal upper limb tone a/t) - power (normal upper limb power a/t) - coordination - rebound test - finger nose test - hand slapping test lower limbs - tone - power - coordination - foot tapping - heel shin test posture/gait - posture - gait |
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rebound test procedure |
o Ask patient to put arms out straight in front and close eyes o Keep your arms in that position o Push each arm down in turn —10cm then release it o Watch for arm bouncing back up to beyond original position if overshoot = dysmetria |
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finger nose test |
Dysmetria, past-pointing Intention tremor (more likely to be seen at extent of arm stretch) |
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remember with the coordination in cerebellar function exam the non dominant side is always |
more difficult |
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hand slapping or foot tapping test assess for |
dysdiadochokinesis |
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heel shin test assess for |
intention tremor, dysmetria |
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when assessing posture in cerebellar function exam what are you looking for |
assess sitting and standing looking for truncal ataxia rombergs test looks for sensory ataxia |
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when assessing gait for cerebellar function what are you assessing |
walking heel to toe |
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additional tests with the cerebellar exam |
full neurological examination inV: MRI for visualising posterior fossa |
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Causes of cerebellar disease |
stroke tumour MS congenital e.g. arnold chiari friedreich's ataxia alcohol abuse thiamine deficiency anti epileptic medication |
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signs of cerebellar lesion DANISH PasTry |
Dysdiadochokinesis (RAM) Ataxia (limb/trunk) Nystagmus Intention tremor Speech (slurred, staccato) Hypotonia Past pointing (dysmetria) ?Tremor at rest |
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Localising the cerebellar lesion |
This may be impossible clinically Lesions may involve both the vermis and hemispheres Central (vermis) lesion symptoms tend to cause - Truncal ataxia sitting & standing - Poor heel-toe - Slurred staccato speech Cerebellar hemisphere Iesion symptoms tend to cause - Ipsilateral limb ataxia (dysmetria, intention tremor, dysdiadochokinesis) - Nystagmus - Unsteady gait, falling towards side of lesion when walking |
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differential for Nystagmus |
Congenital - Pendular nystagmus - Can occur in any direction - Most marked in neutral position Vestibular (apparatus, nerve or pathways eg. labyrinthitis, Meniere’s, syringobulbia, MS) - Unidirectional jerk nystagmus - Fast phases away from side of Ieson - Nystagrnus increases when eyes look in the direction of the fast phase, away from side of lesion (A’exander’s law) Central (brainstem or cerebellar vermis) - Bidirectional jerk nystagmus - Direction of fast phase varies with direction of gaze Unilateral cerebellar hemisphere lesion - Nystagmus when looking in direction of lesion - Fast phase towards lesion |
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differential for dysarthria |
Facial nerve patsy (CN VII) - look for facial weakness Bulbar palsy - look for flaccid, wasted, fasiculating tongue MND GuIIain Barre Syringobulbia Pseudobulbar palsy - look for spastic, contracted tongue MS Bilateral stroke (eg. internal capsule) Myasthenia gravis Cerebellar disease (See above) |
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Wernickes encephalopathy features |
Syndrome resuitng from thiamine (vitamin B1) deficiency Most oases result from alcohol abuse If untreated (with IV thiamine replacement) may progress to irreversible Korsakoff’s psychosis Classical clinical triad 1. Acute confusional state 2. OphthaImoplegia (especially upgaze) 3. Ataxia (and other cerebellar signs) |
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define opthalmoplegia |
paralysis of the muscles within or surrounding the eye |
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exam for signs of cushings syndrome |
Inspection - Central obesity - Peripheral muscle wasting Hands - reduced skin fold thickness Arms - bruising (fragile BVs) - BP (HTN) Face * Moon facies * Acne * Plethora * Hirsutism Chest / Back - Gynaecomastia in male - Intersoapular fat pad ‘buffalo hump’ - Supraclavicular fat pads - Kyphosls Abdomen - purple striae - central obesity Proximal myopathy - test shoulder ABduction power - ask to stand from chair with arms crossed Legs - bruising Extra - Diagnostic tests - Further investigations Blood and urine glucose (DM) U+Es (hypokalemia) Bone scan (osteoporosis) |
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Investigation of non-iatrogenic Cushing’s syndrome |
1. Preliminary diagnosis • Overnight dex suppression testor • 24-hour urinary free cortisol 2. Confirm diagnosis • 48 hour dex suppression test 3. Localise lesion • Plasma ACTH • High dose dex suppression test some suppression suggests Cushing’s disease • Imaging o CT head o MRI pituitary fossa o CT abdomen (adrenals) |
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examination for signs of acromegaly |
Inspect - height - general size Hands - size (large) - increased skin fold thickness - median nerve exam: thenar eminence wasting, thumb ABduction, sensation and special tests - feel palms (boggy/sweaty = active disease) Arms - BP (HTN) Neck - JVP (?raised in cardiomyopathy) - goitre (due to raised GH) Face - Prominent supraorbitat ridges - Prognathism (best seen from side) - Big ears, nose and lips - Large tongue - Show me your gums” o Prognathiern causing underbite o WIde separation of teeth Eyes - visual fields (bitemporal hemianopia) Proximal myopathy - test shoulder aBduction power - stand with arms crossed InV l would arrange an oral glucose tolerance test with growth hormone and IGF-1 measurement’ (failure of GH suppression = confirms dx) * Perform full cardiovascular examination (HTN & cardiomyopathy) * Further Investigations o Blood and urine glucose (DM) o MRI (pituitary adenoma) o ECG (cardiomyopathy) |
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acromegaly diagnosis |
clinical and OGTT with GH and IGF-1 measurement failure of GH suppression = confirms dx |
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Cushings syndrome features |
* Cardiovascular system o Hypertension o Fluid retention (—. CCF) * Gastrointestinal system o Fatty liver o Pancreatitis * Neurological system o Euphoria o Depression o Psychosis o Insomnia * Locomotor system o Proximal myopathy o Osteoporosis + vertebral wedge # o Avascular necrosis * Immune system o Immunosuppression * Endocrine system o Diabetes mellitus * General Cushingoid features o Central obesity o Muscle wasting in limbs o Thin skin o Bruising o Moon facies o Facial plethora o Acne o Hirsutism o Buffalo hump o Gynaecomastia o Purple abdominal striae |
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Indications for long term corticosteroid Rx |
* Respiratory o Asthma o COPD o Pulmonary fibrosis * Gastrointestinal o Inflammatory bowel disease o Autoimmune hepatitis * Rheumatology o RA o SLE o Polymyalgia rheumatica o GCA * Transplant * Replacement doses (do not cause Cushing's) - Addison's disease - Hypopituitarism |
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Causes of Cushing’s syndrome |
* High ACTH o Pituitary adenoma (Gushing’s disease) o Ectopic ACTH (eg. SCLC) * Low ACTH o Adenoma of adrenal cortex o Carcinoma of adrenal cortex o latrogenic (corticosteroid therapy) |
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differential Proximalmyopathy |
* Cushing’s syndrome * Acromegaly * Hyperthyroidism * Muscular dystrophy * PoIymyositis (inflamm. of lots of muscles) * Dermatomyositis (inflam. of mus & skin) * Myasthenia gravis * Hypo / hyper K * Hypo / hyper Ca2+ |
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Features of derrnatomyositis |
* Proximal myopathy * Heliotrope facial rash * Gottron’s papules (extensor surfaces of fingers) |
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treatment for acromegaly |
Trans-sphenoidal resection of tumour Bromocripline / Octreotide / ?cabergoline - used to reduce GH synthesis - used in young adults due to high risk of infertility following surgery - may also be used pre-operatively |
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Rheumatology hand exam |
LOOK - wrists - dorsum - MCP - fingers - nails - palmar side -praying position - make fist (valleys) - fists up to chin - ears, neck & scalp Feel - dupuytrons - nodes/nodules - ToC - Squeeze MCP Move: hand function - power grip - precision grip - hold hands out and wiggle fingers (crude for hand func) - button Move: upper limb function - arms out - cock wrists back - supination and pronation - hands to chest - hands behind head ( shoulder ABd & ext rotxn) - slide hands behind back (internal rotation) Neurological assessment: for median, ulnar and radial nerves - Sensation - Power - Special tests Concluding remarks I would like to examine the rest of the musculoskeletal system Examination of other systems where applicable . 1 investigations: X-ray, ESR / CRP, Rheumatoid factor |
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‘Examine this patient’s hands’ cases — modify your examination based on what you find |
* Musculoskeletal: OA, RA, psoriatic arthropathy, gout * Neurological: Median nerve palsy (carpal tunnel), ulnar nerve palsy (check for elbow trauma)- radial nerve palsy, TI lesion, MND * Endocrine: Thyroid disease acromegaly * Remote pathology: Clubbing, leuconychia, koilonychia |
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RA statistics |
* 3 females :1 male * Peak prevalence age 30— 50 * 70% seropositive (as is 5% of general populatIon) o Rheumatoid factor ÷ve (1gM against self-lgG) o Often have nodules o Extra-articular features o Progressive disease * 20% of all RA patients have nodules * 50% HLA-DR4 +ve (severe, erosive disease) |
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Extra-articular features of RA |
* General: Malaise, lethargy, low grade fever, weight loss * CVS: Pericarditis, pericardial effusion * RS: Nodules, pleural effusion, pulmonary fibrosis, pneumoconiosis (Caplan’s syndrome) * GUS: Renal amyloid * NS: Polyneuropathy, mononeuritis multiple, carpal tunnel, atlanto-axial subluxation * Eyes: Scleritis, episcleritis, keratoconjunctivitis sicca, Sjogren’s syndrome * Blood: Anaemia, thrombocytosis, down WCC (Felty’s syndrome = down WCC + splenomegaly + RA) |
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Multifactorial aetiology of anaemia in RA |
* Anaemia of chronic disease * Iron deficiency anaemia secondary to NSAID-induced gastritis / peptic ulcer * Aplastic anaemia secondary to DMARD therapy * Macrocytic anaemia secondary to methotrexate * Pernicious anaemia (associated with RA) |
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Sjogren’s syndrome |
* dry eyes (keratoconjunotivitis sioca), dry mouth (xerostomia) & parotid gland enlargement * May occur independently, or associated with RA I SLE I scieroderma |
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RA X-Ray |
* Loss of joint space * Bony erosions * Periarticular osteoporosis * Deformity (eg. subluxation) * Soft tissue swelling |
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OA X-Ray |
• Loss of joint space • Osteophytes • Subchondral sclerosis • Bone cysts |
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Psoriatic arthropathy |
Affects 10% of patients with psoriasis In 75% skin features present before arthropathy In 20% skin features present after arthropathy In 6% no skin features will ever appear |
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Presentations of psoriatic arthropathy |
• Assymetrical oligoarthritis o Mainly hands and feet (dactylitis) o Sometimes larger joints • Lone DIP disease • Rheumatoid pattern • Arthritis mutilans • Sacroiliitis |
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groin hernia exam |
Intro: - position: if supine and obvious do exam; if not obvious do exam standing, if px already standing then do standing - where is it? Inspection: - both sides - scars - give me a cough and check visible cough impulse Palpation (let me know if discomfort) - normal side + cough - affected side: size, tension/hot/tender, i.d lower extent, cough impulse - Locate pubic tubercle: above = inguinal; below = femoral - palpate scrotum if male: extension of groin swelling; try get above it Reduction - px reduce - px can't = you try - you can't = try supine/standing - if reducible locate deep ring (middle of inguinal canal) - contain hernia: reduce; occlude deep ring and ask to cough Auscultate - over lump for bowel sounds * It not done: would like to examine the contralateral groin * If examined supine: would like to examine the groins with the patient standing to check for a small hernia on the contralateral side * I would like to perform a full abdominal exam, in particular looking for a cause of raised intra-abdomirial pressure’ * Transillumination of any scrotal mass |
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Definition of a hernia:
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The protrusiqn of whole or part of a viscus through an opening in the wall of its containing cavity into a place where it is not normally found. |
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Borders of Hesselbach’s triangle |
* Inferior epigastric artery * Inguinal ligament * Linea semilunaris (lateral border of rectus muscle) |
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Types of surgical hernia repair |
* Open mesh repair (Lichtenstein) * Open suture repair (Babinski / Shouldice) * Laparosoopic o TEP (total extraperitoneal procedure) o TAP (trans-abdominal procedure) |
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Risk factors for developing hernia |
* Family history * Weakness of abdominal musculature o Increasing age (especially direct) o Surgery (incisional hernia) * Increased intra-abdominal pressure o Obesity o Pregnancy o COPD / chronic cough o Prostatism o Constipation o Heavy lifting |
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Complications of a hernia; |
Incarceration (irreducible) can lead to: 1. Obstruction (clinically: colic, constipation, vomiting, distension) 2. Strangulation: lschaemia —‘ Necrosis —, Peritonitis |
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Richter’s hernia |
* Only part of the bowel wall herniates, allowing strangulation without obstruction- * More common in femoral hernia (narrower orifice) |
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walls of the inguinal canal |
roof = internal oblique and conjoint tendon back wall = transversalis fascia deep ring = transversalis fascia front wall = external oblique floor = inguinal ligament superficial ring = external oblique |
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thyroid, neck lump and thyroid status exam |
Intro General Inspection * thin, fidgety, trerulous, sweaty, hushed, restless * Fat, warmly dressed, hair loss dry skin, deep voice Thyroid Status (Assess in any patient with goitre or thyroid symptoms) - hands & wrist: acropachy, palms (ToC), palmar erythema (hyperthyroid), fine tremor (hypER), Pulse (tachy = hyPER, brady = hyPO) - face: flushed (hyPER), hair & eyebrow (thin, brittle = hyPO), eyes: exop and lid lad (hyPER) eye movements: double vision and opthalmoplegia = hyPER Lid lad (hyper) Thyroid / Neck Lump Inspection: - point - look: front and sides - define location: midline, anterior/posterior - swallow: sip & hold and swallow, watch from front then side - stick out tongue Palpation of neck lump (from behind) - pain? - start at centre then to edges - size, shape, symmetry, surface, consistency, edge, fluctuance, pulsation specific to thyroid swelling - diffuse enlargement or single nodule - if diffuse - smooth/multinodular - can you get below it get patient to swallow try transilluminate with lamp palpate nodes Percuss down to sternum Auscultate both sides of lump (hold breath) Special tests: Pemberton's test Limbs - bicep and knee reflex (brisk = HYPer; slow = HYPO) - check for carpal tunnel (hyPO) - power, sensation, special tests - proximal myopathy - shoulder and stand up - edema - pretibial myxodema (Graves); generalised (hyPO) |
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ddx for neck lump |
midline o Goitre o Thyroglossal cyst Anterior triangle o Branchial cyst — under the top of SCM o Carotid body tumour o Lymph node Posterior triangle o Cystic hygroma (above clavicle) o Lymph node Anywhere o Sebaceous cyst o Lipoma |
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Multinodular goitre (MNG) |
* Most common large goitre * Can be smooth rather than multinodular to feel * Patient usually euthyroid = non-toxic MNG * Hyperthyroid = toxic MNG * Indications for surgery in non-toxic MNG o Cosmetic o Local compression effect |
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Grave’s disease |
* Classic features o Goitre o Thyrotoxicosis o Eye disease (50%) * Exopthalmos Unique to Grave’s * Ophthalmoplegia Unique to Grave’s o Pretibial myxoedema Unique to Grave’s o Thyroid acropachy Unique to Grave’s * Factors differentiating from toxic MNG o Smooth goitre (MNG rarely smooth) o Grave’s-unique features as above o TSH-receptor antibodies * Indications for surgery o Cosmetic o Local compression o Failed medical Rx o Intolerant of medication |
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A note on thyroid eye signs |
* Any cause of hyperthyroidism o Lid retraction o Lid lag * Specific to Grave’s disease o Exopthalmos o Qphthalmoplegia |
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Differential for Goitre |
* Multinodu jar goitre * Grave’s disease * Solitary nodule (adenoma I carcinoma) * Hashimoto’s thyroiditis * Subacute thyroiditis |
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Differential for Hypothyroidism |
* Autoimmune o Primary atrophic thyroiditis (no goitre) o Hashimoto’s initially * Acquired o Iodine deficiency (number one cause worldwide) o Subacute thyroiditis o latrogenic - Surgery - Radioiodine - Carbimazole - Lithium - Amiodarone * Secondary o Panhypopituitarism (very rare) |
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differential for Parotid swelling |
Bilateral o Viral / bacterial parotitis o TBo Alcohol o Pleomorphic adenoma o Sjogren’s o Sarcoidosis Unilateral o Duct blockage o Unilateral pleomorphic adenoma |
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Hyperthyroidism treatment |
* Medical o Symptomatic control: b-blockers o Anti-thyroid therapy: Carbimazole * Radioiodine * Surgical (cosmetic, compression, malignancy) o Total thyroidectomy o Subtotal thyroidectomy |
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Contraindications to radioiodine |
* Pregnancy! breast feeding * Young children at home * Incontinent (eliminated in urine) |
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Complications of thyroidectomy |
Complications of thyroidectomy Early o Anaesthetic I haemorrhage I infection o Damage to surrounding structures * Recurrent laryngeal nerve * Trachea * Qesophagus * Neck musculature o Transient hypoparathyroidisrn
Late o Hypoparathyroidism o Recurrent hyperthyroidism o Hypothyroidism |
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Beware the patient with one red foot and one pale foot (often with rapid capillary refill in the red foot) |
* Easy to think the white foot is the ischaemic one * In fact the whiter foot may be normal, with the red foot occuring due to dependent pooling of venous blood in a chronically ischaemic limb (the patient may have been sifting up in a chair prior to you arriving) * Before commenting, feel the temperature of the feet and see what happens to the red foot when it iselevated from the bedit ischaemic it will rapidly exsanguinate and become very pale |
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Causes of ‘claudication’ in presence of normal peripheral pulses: |
1. Neurogenic claudication (spinal stenosis)
2. Anaemia 3. B blockers |
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Critically ischaemic limb (6 Ps) |
Pain pallor pulseless perishingly cold paresthesia paralysis (BEST INDICATOR OF DANGER TO LIMB) |
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ABPI measurements |
.8 - 1.2 Normal <0.8 = intermittent claudication, rest pain/critical limb ischemia, gangrene + ulceration >1.2 = calcification |
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Leriche’s syndrome: |
Bilateral buttock pain and erectile impotence due to common iliac disease. |
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Venous ulcers FEATURES |
HISTORY * Varicose veins * DVTs CLASSIC SITES * Medial gaiter region of leg EDGES * Sloped EXUDATE * Lots PAIN * Not severe unless associated with excessive oedema or infection EDEMA • Usually associated limb oedema ASSOCIATED FEATURES * Venous eczema * Haemosiderosis * Lipoderrnatosclerosis * Atrophie blanche MANAGEMENT * Graduated compression dressing * Antibiotics for infection |
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Arterial Ulcer FEATURES |
HISTORY * Intermittent claudication * Rest pain CLASSIC SITES * Feet / toes * Ankle (lateral maleolus) EDGES * Punched-out EXUDATE * Usually little PAIN * Painful EDEMA * Cedema uncommon ASSOCIATED FEATURES * Trophic changes * Gangrene MANAGEMENT * Conservative * Endovascular revascularization (angioplasty) * Surgical revascularization o Depends on sites of disease o Fem-pop bypass o Fern-dIstal bypass o Axillo-femoral bypass o Aorto-bifemoral graft |
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Diabetic foot features |
* Peripheral nouropathy o Loss of ankle jerk and vibration sense o Accidental injury / tissue damage (contributes to ulcer formation) o Charcot joints (neuropathic arthropathy) * Large vessel arterial disease (contributes to ulcer formation) * Small vessel arterial disease (contributes to ulcer formation) |
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* Autonomic neuropathy features |
o Reduced sweating o Dry, cracked skin (contributes to ulcer formation) o Infection (contributes to ulcer formation) |
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Varicose veins |
* Occur as a result of valvular incompetence o Structural predisposition (familial tendency) o Factors that increase venous pressure: prolonged standing, obesity, pregnancy * Sites of incompetence o Saphenofemoral junction (SFJ) — typically causes long saphenous vein (LSV) varices o Saphenopopliteal junction (SPJ) — typically causes short saphenous vein (SSV) varices o Perforating veins linking deep veins and saphenous systems * Often associated with signs of chronic venous insufficiency |
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Management of varicose veins |
* Conservative o Elastic support hose o Weight loss o Regular exercise o Avoid prolonged standing * injection ,sclerotherapy o Suitable for small varices below knee due to incompetence of local perforators o Not satisfactory for varices associated with SFJ incompetence (recurrence inevitable) * Surgery o SFJ incompetence & LSV varices - SFJ ligated (a so-called ‘high tie’) - LSV usually stripped from knee to groin (reduced chance of recurrence) - Stab avulsions of remaining varices o SPJ incompetence & SSV varices * SPJ ligated (SSV not stripped due to risk of damaging sural nerve) * Stab avulsions of remaining varices * New techniques o Ultrasound-guided foam sclerotherapy o Radiofrequency or laser obliteration of LSV I SSV |
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Causes of chronic venous insufficiency nb Chronic venous insufficiency 20 DVT is also known as ‘post-thrombotic syndrome’ |
1. Valvular incompetence of deep veins (90%) o Primary (aetiology same as for varicose veins) o Secondary (damaged by DVT) 2. Obstruction of deep veins by Dv1 (10%) |
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Superficial thrombophlebitis |
* Inflammation and thrombosis almost invariably occurring in varicose veins * Redness and tenderness follow line of vein * Thrombosis may spread to deep system and cause DVT * Management o Analgesiac NSAIDs o Support stockings o Active exercise * Underlying vein usually removed as recurrence is common * Propagation towards deep veins is an indication for IV heparin |
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Examination of a Lump |
Introduction - wheres the lump? anymore? Inspection - site - location - size and shape - overlying skin: color, punctum, discharge Palpate lump - discomfort (start at center) - surface, consistency, heat, tender\ - move to borders: shape, size, edge - fluctuence - attachment to skin (slide skin over lump - impossible if intradermal) - attachment to other structures - contract muscle (see if attached to mus), move joint (see if ganglion) - feel for special characteristics: thrill, pulsation - transilluminate with pen torch Palpation of near by lymph nodes Auscultation if thrill/pulsatile * If not done: Iwould like to assess for regional lymphadenopathy” * ‘I would like to enquIre about any recent changes which might raise suspicion of a malignant lump” o Increasing size o Changing surface / consistency / edge o Development of associated pain * Investigations: FNA. imaging |
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Examination of a Skin Lesion |
Introduction - abn? where? Inspection - site, distribution - size - shape - border - colour - discharge Palpation - feel if elevated - tender - hot ‘I would like to proceed to examine the rest of the patient’s skin as well as performing a full systemic examination.’investigations: bloods, biopsy, serial photographs |
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breast exam |
male genitalia exam |
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Intradermal lumps (impossible to slide skin over) |
* Sebaceous cyst * Abscess * Dermoid cyst * Granuloma |
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Subcutaneous lumps (skin can slide over) |
* Lipoma * Ganglion * Neurofibroma * Lymph node (See Appendix A] |
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Lipoma features |
Benign fatty tumor Anywhere fat can expand (not scalp or palms) Subcutaneous Smooth Imprecise margins Fluctuant Symptoms 2o pressure effects Malignant change (very rare) Conservative Excision for cosmetic reasons or local pressure effects |
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Sebaceous Cyst features |
Epidemial proliferation within dermis Anywhere on body (most common on trunk, neck, face & scalp) Intradermal Central punctum Infection common MGMT Incision & drainage if infected Occasionally antibiotics needed Non-infected cysts can be ‘shelled out’ under local |
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Ganglion features |
Degenerative cyst from synovum of joint! tendon Dorsum of hand / wrist Dorsal foot Subcutaneous Move with tendon May transilluminate Rare MGMT Conservative (50% disappear) Aspiration Excision ‘Blow from bible’ (not advised!) |
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Examination of a Skin Lesion: Notes |
Common skin lesions* Melanocytic naevus (mole)* Urticaria* Eczema* Ulcers lSee below]* Spider naevia* Campbell di Morgan spots* Striae (eg. Cushing’s syndrome)* Skin tags* Psoriasis* Seborrhoeic keratosis* Erythema nodosum [See Section 4]* Tumouro Melanomao Squamous cell carcinoma o Basal cell carcinoma* Neurofibromatosis (common in OSCEsI) o Neurofibromatao Café au lait spots |
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Neurofibromatosis |
* Genetic disorder * 2 variants (Type Iand Type 2) * Both types have autosomal dominant inheritance * Type I= Von Recklinghausen’s disease (This neurofibroma always CATCHES on my clothes) o Cafe au Jait patches (>6 is diagnostic) o Axillary freckling o Tumours of nervous system o Cutaneous neurofibromata o Hypertension o Eye features (Lisch nodule) o Scoliosis * Type2 o Bilateral acoustic neuromas (key feature) o Other turnouts of nervous system o Fewer cutaneous features |
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Warning signs of a melanoma (ABCDE) |
* Asymmetry * Border irregularity * Colour variation * Diameter (> 6mm or increasing) * Elevation |
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differential for Ulcer by type of edge |
* Sloping Venous * Punched-out Arterial * Undermined = TB, pressure necrosis * Rolling = Basal cell carcinoma (‘rodent ulcer’) * Everted = Squamous cell carcinoma |
